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Terrence L. Cascino, MD, FAAN, professor of neurology and neuro-oncology at the Mayo Clinic in Rochester, MN, had been noticing some troubling trends in recent reports on satisfaction in the physician workforce. In particular, a 2012 survey on the rate of burnout among US physicians by specialty stood out. That study, published in the Archives of Internal Medicine, and led by Tait D. Shanafelt, MD, professor of medicine at Mayo Clinic, found that neurologists reported the highest rate of burnout and career dissatisfaction.

“I discussed with Dr. Shanafelt the reason why that might be,” Dr. Cascino said. “It wasn't clear. That's when I became interested in the topic of neurology burnout as a big risk.” When Dr. Cascino was elected president of the AAN in 2015, he continued, “I wanted to make it a priority to understand this problem of burnout, find the causes, and see if anything could be done about it.”

To that end, Dr. Cascino, working with his predecessor Dr. Timothy Pedley, MD, FAAN, formed the AAN Burnout Task Force to study neurologist burnout, career satisfaction, and work–life balance; determine associated factors; and develop and disseminate evidence-based resources to mitigate burnout and enhance career satisfaction.

The co-chairs of the AAN Burnout Task Force Study Group, Neil A. Busis, MD, FAAN, clinical professor of neurology at the University of Pittsburgh School of Medicine, and Kerry H. Levin, MD, FAAN, chairman of neurology at Cleveland Clinic and professor of medicine (neurology) at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University in Cleveland, Ohio, led the development of a 57-question survey to be completed by AAN member neurologists between January and March of 2016. The survey built on statistical tools that Dr. Shanafelt, a member of the task force, had used in his research, but added a number of neurology-specific factors to investigate underlying causes.

A total of 1,671 US AAN member neurologists (out of 4,127) responded, corresponding to a 40.5 percent response rate. “I've never seen such a big response,” Dr. Cascino said. “It was obvious that this resonated.”

The 2016 findings were consistent with Dr. Shanafelt's 2012 paper. Among the striking results, six out of 10 AAN member neurologists reported at least one symptom of burnout, and they generally reported higher levels of career dissatisfaction and career-life imbalance than physicians in other specialties. A number of factors, including hours worked per week, the number of nights on call per week, and the burden of clerical work, were associated with a higher risk of burnout.

Neurology Today spoke with Dr. Busis and Dr. Cascino in separate phone calls about the survey findings and how the AAN plans to address the problem of burnout. Following are edited excerpts from the interviews.

WHY IS BURNOUT A CONCERN IN NEUROLOGY?

DR. BUSIS: We know from previous literature that burnout can cause physicians to practice less effectively, cut back hours, leave the field early, or deter them from entering the field.

In 2013, the AAN formed a workforce task force, which found that demand for neurologists exceeded supply, and we know that by 2025 that demand for our services will be even higher. The combination of having the highest burnout and the lowest work-life satisfaction will only exacerbate the supply-demand problem. The mission of the AAN is to promote the highest-quality, patient-centered care and to promote career satisfaction among neurologists. Burnout challenges both of those goals.

HOW DID YOU DESIGN THE SURVEY?

DR. CASCINO: We began by using validated surveys that had been used in other papers, including the Maslach Burnout Inventory. We wanted to use tools that we could match up to other surveys and were scientifically valid. Then we added on neurology-type factors so we could look to potential causes.

DR. BUSIS: That allowed us to do two things: We were better able to compare across all different specialties and to identify specific trends in neurology.

CAN YOU DESCRIBE THE SURVEY'S MOST IMPORTANT FINDINGS?

DR. CASCINO: Burnout is high in neurology. Sixty percent of people have one symptom. Also, burnout is ubiquitous. It's higher for people in private practice than academics, but it is present in both [sectors]. We thought perhaps that subspecialties under strain — those with longer work hours and more complex patients — might have higher burnout, but that did not bear up. The subspecialties were about the same statistically.

WHAT FACTORS WERE ASSOCIATED WITH BURNOUT IN NEUROLOGY?

DR. BUSIS: The major factors were clerical burden, hours worked per week, patients seen per week, and nights on call per week. Factors that decreased burnout were autonomy on the job, effective support staff, meaningfulness of work, older age, and the subspecialty of epilepsy. Of those independent drivers, all except epilepsy are common to all physicians. It appears that when you think about why neurologists are more burned out, it's mostly the same drivers [as in other specialties] but they're more potent, rather than ones that are unique to neurology.

CAN YOU COMMENT ON DIFFERENCES IN CAREER SATISFACTION BY SUBSPECIALTY (LOWER RATES OF BURNOUT IN THE SUBSPECIALTY OF EPILEPSY AND LOWER RATES OF PROFESSIONAL SATISFACTION IN THE SUBSPECIALTY OF SLEEP)?

DR. BUSIS: Our results provide a high-level overview of factors associated with increased burnout, decreased career satisfaction, and well-being in neurologists and why neurology fared poorly compared to other specialties, but they are insufficient to determine all of the underlying reasons. Additional studies, including qualitative analysis of the free text comments many respondents contributed to our survey, may provide further insights.

THE SURVEY FOUND A DISPARITY BETWEEN ACADEMIC AND CLINICAL NEUROLOGISTS. WHY DO YOU THINK THAT IS?

DR. BUSIS: There is a clear difference between these two groups: 55.7 percent of neurologists in academic practice are burned out versus 66.3 percent of neurologists in clinical practice. One factor is compensation. Academic practice neurologists tend to have a straight salary more often than those in clinical practice, who more commonly have a production-based income. Although the number of hours worked per week was actually greater in academic practice than in clinical, the kind of work is different. Neurologists in academic practice did less clinical work and more research, teaching, and administrative work.

DR. CASCINO: Often neurologists in academic practice have more ancillary help – scribes, people doing dictation. You see more engagement. In an academic center, you don't see patients every day, so the clinical load is lower. They have a greater variety of activities like teaching residents and other organizational activities. There's more of an opportunity for national involvement and engagement. You may have time for it and more of an entry into that.

ANY MORE ENCOURAGING NEWS FROM THE SURVEY?

DR. CASCINO: Neurologists are satisfied seeing neurology patients. Almost 90 percent said their work is meaningful — people really feel they're doing something to help patients. They feel they have autonomy in their work. And 65 percent would become neurologists again. That could be a good thing, but then again, 35 percent wouldn't.

I think the thing that gives me most hope is the reason for burnout is not neurology. It's not seeing depressing and incurable diseases. It's other issues. I think we can mitigate those concerns, nationally or individually, if we can make the problem visible, then talk about what we can do to address it.

HOW DO THE STUDY'S FINDINGS FIT INTO THE BROADER CONTEXT OF MEDICINE?

DR. CASCINO: Burnout is universal in physicians. This is not a neurology problem. We have a high burnout rate, but other specialties do too, and they appear to be getting worse. This has more to do with the practice of medicine. It's clear that burnout is increasing and widespread.

What we have concluded [from these findings] is, one of the key drivers of burnout is what we call regulatory hassles, which produce no added value. Regulations that make patients safer or that increase quality of care are obviously needed and reasonable. But regulatory hassles or burdens that produce no increased value lead to a lot of frustration.

Time-management studies have shown the enormous amount of time by physicians doing things other than patient care. The physician sees patients and then they spend twice as much time doing other things: working on the electronic health record (EHR), insurance things, forms, making calls, having to wait and get permission for drug approvals. To the degree those add value, that's one thing. To the degree they don't, that's a huge source of frustration.

WHAT DOES THE AAN PLAN TO DO TO ADDRESS THE PROBLEM OF BURNOUT?

DR. BUSIS: We plan to try to improve burnout at three levels: the individual (the practice, work unit, or department), the organization (the practice or neurology department), and the national level.

DR. CASCINO: At the individual level, engagement is huge. We have many examples of individuals who appear to have the same practice, salary, and patients, yet one is engaged and positive about neurology while the other is burned out and doesn't know if they can continue. What is the difference? It has to do [partly] with the ability of the person to be resilient to burnout. This is not a character flaw. But what we've found is that people who get more engaged in other activities [outside of neurology] appear to have a lower rate of burnout.

DR. BUSIS: Engagement is the opposite of burnout. We should promote mindfulness, self-care, self-management, and communication. There will be a number of opportunities for these activities. The Live Well area of the AAN website is a great resource. We plan to develop even more web resources.

Then, at the AAN Annual Meeting [in Boston next month], there will be live programs on yoga and meditation and talks on how to reduce regulatory hassles. Some coaches will perform one-on-one mentoring at the Live Well area. After the meeting, we hope to share the content on the Live Well website.

In the fall of 2017, we are initiating a program called Leading Well. It will be similar to the Palatucci Advocacy Leadership Forum, but for wellness. It will be a yearlong program starting with a two-day retreat. We want to train the trainers. A lot of burnout issues are local. Our hope is that participants who complete the program will go back [to their practice or institution] and promote engagement and wellness where they work. We plan to collect success stories and make them available to other practices and organizations.

We also need to make sure that organizations recognize this is a problem in the first place – many still don't. The first steps are getting leadership to recognize this as a problem, then address it. Ultimately, just as we have clinical practice guidelines, we would like to disseminate best practices to reduce burnout, increase career satisfaction, and promote neurologist engagement to organizations.

DR. CASCINO: These best practices should aim to help neurologists become more effective or efficient so there is less of a burden and time is spent only where it should be. We want to encourage practices that promote face-to-face time talking with patients.

DR. BUSIS: At the national level, we need to advocate for physician-friendly national policies, meaningful quality measures, and fair reimbursements. There has been progress recently on that front. In the fall of 2016, the 21st Century Cures Act was passed, which decreases regulatory hassles and expedites the interoperability of the EHR. The Centers for Medicare and Medicaid Services (CMS) has created a new office of clinician engagement.

DR. CASCINO: When we go to Neurology on the Hill [an annual advocacy event where neurologists meet face-to-face with lawmakers], meet with the CMS, and go to Congress for visits, the message we have to craft is that regulatory hassles that add no value are a driver of physician burnout that leads to early retirement, a change in careers, and not to better value for the health system but worse value. We will look for partners and other groups that feel the same way.

I also think we have an opportunity with the change in leadership in health care. The new Health and Human Services secretary and new CMS director are aware of how we feel.

DR. BUSIS: At Neurology on the Hill, we will discuss issues like drug pricing, which actually has a lot to do with burnout. If drugs were cheaper, you wouldn't have to spend as much time on preauthorization. Some drugs, like IVIG, take hours to get authorized. Another thing we hope for is to make tools like EHRs easier, not harder to use. We can improve health information technology in order to reduce the clerical burden that interferes with patient care.

DO YOU SEE A BRIGHT FUTURE FOR NEUROLOGY?

DR. CASCINO: After I've studied this for four years, am I pessimistic or optimistic? I'm optimistic. I think what's best for patients will ultimately win out, and what's best for patients will be best for neurologists. Regulatory hassles that produce no value will be diminished over time. I think we will have a workforce of neurologists who are dedicated and very engaged in their specialty.